Purpose: Low density lipoprotein cholesterol (LDL-C) is primary treatment target for patients with dislipidemia. The apolipoprotein B (apo B), an emerging biomarker for cardiovascular risk prediction, appears to be superior to the LDL-C. However, little is known about goal attainments and their discrepancies for LDL-C and apo B in Chinese patients with known CAD or DM.

1. © Cardiovascular Diagnosis and Therapy. All rights reserved. Cardiovasc Diagn Ther 2015;5(2):98-103www.thecdt.org
Introduction
Cardiovascular diseases due to atherosclerosis of the arterial
vessel wall and to thrombosis are the foremost cause of
premature mortality and of disability-adjusted life years in
the developed countries and are also increasingly common
ones in developing countries (1). It is acknowledged that
patients with diabetes mellitus (DM) are susceptible to
coronary artery disease (CAD) and that the coexistence of
both diseases is common in clinical practice. According
to recently published guidelines, persons with established
CAD or CAD risk equivalents, such as DM, are categorized
into high risk and need similarly active management of
dyslipidemia (2). Thus, it’s reasonable these 2 diseases
are put together under investigation. Lipid metabolism
can be disturbed in different ways, leading to changes in
plasma lipoprotein function and/or levels. This by itself and
through interaction with other cardiovascular risk factors
may affect the development of atherosclerosis. The lipid
evaluation includes total cholesterol (TC), triglycerides
Original Article
Goal attainments and their discrepancies for low density
lipoprotein cholesterol (LDL-C) and apolipoprotein B (apo B) in
over 2,000 Chinese patients with known coronary artery disease
or type 2 diabetes
Yong-Ming He, Xiang-Jun Yang, Xin Zhao, Hai-Feng Xu
Division of Cardiology, the First Affiliated Hospital of Soochow University, Suzhou 215006, China
Correspondence to: Yong-Ming He. Division of Cardiology, the First Affiliated Hospital of Soochow University, Suzhou 215006, China.
Email: heyongming@suda.edu.cn.
Purpose: Low density lipoprotein cholesterol (LDL-C) is primary treatment target for patients with
dislipidemia. The apolipoprotein B (apo B), an emerging biomarker for cardiovascular risk prediction,
appears to be superior to the LDL-C. However, little is known about goal attainments and their
discrepancies for LDL-C and apo B in Chinese patients with known CAD or DM.
Methods: A total of 2,172 hospitalized patients with known coronary artery disease (CAD) or DM, aged
>27 years of old, were enrolled. The success rates for apo B and LDL-C goal attainments were evaluated and
compared by categorization and by sex.
Results: When the success rates for apo B were compared with the ones for LDL-C, the former was higher
than the latter across all categorizations, with the statistically significant differences seen in all patients, CAD
alone and DM alone (P<0.0001), but not in coexistence of CAD and DM (P=0.190). The trend toward to
higher success rates for LDL-C and apo B goal attainments in men than in women were noteworthy across
all categorizations although only in all patients and in DM alone patients were the statistically significant
differences found (P<0.01).
Conclusions: The LDL-C lags behind the apo B in goal attainments in Chinese patients. Whether these
discrepancies are associated with the occurrence differences for CAD and for stroke between the East Asia
and the Western countries warrants further study.
Keywords: Apolipoprotein B (apo B); low density lipoprotein cholesterol (LDL-C); goal attainments; coronary
artery disease (CAD); diabetes mellitus (DM)
Submitted Jan 25, 2015. Accepted for publication Feb 28, 2015.
doi: 10.3978/j.issn.2223-3652.2015.03.04
View this article at: http://dx.doi.org/10.3978/j.issn.2223-3652.2015.03.04

2. 99Cardiovascular Diagnosis and Therapy, Vol 5, No 2 April 2015
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(TG), high density lipoprotein cholesterol (HDL-C), low
density lipoprotein cholesterol (LDL-C), apolipoprotein B
(apo B), apolipoprotein (apo A1) and lipoprotein (a) [Lp(a)],
among which LDL-C is acknowledged as the primary
target of therapy on one hand. On the other hand, the
apo B, the number of the atherogenic apo B lipoprotein
particles, has been emerging as a more accurate biomarker
for cardiovascular risk prediction compared with the
traditional LDL-C. The superiority of apo B over LDL-C
has been confirmed by several large clinical studies (3-5)
and Meta analyses (6). Given the importance of LDL-C and
apo B, little is known, however, about LDL-C and apo B
goal attainments and their discrepancies in Chinese patients
with known CAD or DM on stable therapy for at least
3 months. Moreover, as of the present time, there has been no
relatively large-scale sample study to compare the both goal
attainments in Chinese patients with known CAD or DM.
Methods
Patients
A total of 2,172 hospitalized patients aged >27 years of old were
enrolled from Jan. 1st
2009 to Dec. 31st
2012. They had been
on stable therapy for CAD or type 2 DM for at least 3 months.
Lipid profile measure and definitions
A venous blood sample was drawn after fasting 8 h and
all samples were analyzed in a central laboratory for TC,
HDL-C, LDL-C, TG, apo B, apo A1, Lp(a), and blood
sugar. The TC, TG, HDL-C and LDL-C concentrations
were determined directly by the colorimetry according to
the enzymatic principle. The apo B concentrations were
determined directly by the immuno-turbidimeters. The
related reagents were purchased from Sekisui Medical
CO., LTD. CAD diagnosis with coronary artery diameter
stenosis of ≥50% was confirmed by coronary angiogram.
DM diagnosis was based on fasting glucose ≥7.0 mmol/L
recommended by American Diabetes Association (7) or on
patients’ histories of hypoglycemic therapy. Primary hypertension
was diagnosed based on the blood pressure ≥140/90 mmHg
or on patients’ histories of antihypertensive therapy.
Interventions and designs
This is an observational study for hospitalized patients, who
were on stable therapy for at least 3 months. These patients
were divided into four groups: all patients, including CAD
or DM, but not excluding any other diagnoses; CAD alone,
excluding DM, but perhaps including any other diagnoses;
DM alone, excluding CAD, but perhaps including any
other diagnoses; the coexistence of CAD and DM, but
not excluding any other diagnoses. Stable therapy meant
standard care of aspirin, β-blockers, angiotensin converting
enzyme inhibitor, clopidogrel and statins for CAD patients
and all kinds of hypoglycemics for DM ones, and also
included appropriate drug adjustments for CAD or DM at
the discretion of physicians.
Primary endpoint
According to the ESC/EAS guidelines for the management
of dyslipidemia (1), documented CAD or DM has been
stratified into very high risk, and the treatment target
for LDL-C is <1.8 mmol/L and for apo B <0.8 g/L,
respectively.
For this study, the primary endpoint was success rate,
defined as the proportion of patients achieving apo B
treatment goal according to the ESC/EAS guideline (1).
The apo B goal attainment are <0.8 g/L for very high risk
patients. The apo B goal attainment was evaluated for
all patients included, for varying categorizations and for
different sexes. The percentages of patients who were not
at their LDL-C goals, but at their apo B goals were also
determined. The apo B goals were compared across varying
categorizations and genders.
Statistical analysis
Continuous variables are expressed as median (25th
-75th
percentile) as all of these variables are not distributed
normally. Categorical variables are expressed as percentages.
Independent samples of continuous variables or categorical
variables across the groups were compared by Kruskal-
Wallis equality-of-populations rank test or by Pearson
χ2
. A 2-tailed P value <0.05 was considered statistically
significant. The statistical analyses were completed using
STATA 12.0 software.
Results
Clinical and lab characteristics of over 2,000 patients
Table 1 shows the clinical and laboratory characteristics
of the 2,172 patients included according to varying

3. 100 He et al. Goal attainments and their discrepancies for LDL cholesterol and apo B
© Cardiovascular Diagnosis and Therapy. All rights reserved. Cardiovasc Diagn Ther 2015;5(2):98-103www.thecdt.org
categorizations. The male patients were dominant across
all categorizations. The percentages of hypertension were
high across all categorizations, among which the highest
percentage (79.28%) was found in DM alone patients, and
the lowest percentage was found in CAD alone patients,
but also reaching up to 66.94%. Overall, 59.78% of men
received lipid lowing therapy as compared with 48.06% of
women, with the difference being 10 percentage points in
all patients (P<0.0001). The same trends toward to higher
proportion of lipid lowing therapy in men than in women
have been found across categorizations although only in
DM alone was the statistical difference found (P<0.0001).
LDL-C and apo-B goal attainments by categorization and
by sex
Overall, 26.15% and 37.80% of patients attained LDL-C
and apo-B goals, respectively. When the success rates of
LDL-C and apo B were evaluated by categorization, the
success rates were lowest (18.29% and 30.70%, respectively)
in DM alone patients as compared with CAD alone patients
(44.29% and 55.71%, respectively) or with coexistence of
CAD and DM patients (40.00% and 46.50%, respectively)
(between-group comparisons, P<0.0001). The trend toward
to higher success rates for LDL-C and apo B in men than in
women has been found across all categorizations although
only in all patients and in DM alone were the statistically
significant differences found (P<0.0001). See Table 2.
Interestingly, when the success rates for apo B were
compared with the ones for LDL-C, the apo B goal
attainment rates were higher than the LDL-C’s across all
categorizations, with the statistically significant differences
seen in all patients, CAD alone and DM alone (P=0.000),
but not in coexistence of CAD and DM (P=0.190). The
trend toward to higher success rates for LDL-C and apo B
goal attainments in men than in women are marked across
all categorizations although only in all patients and in DM
alone patients were the statistically significant differences
found (P<0.01).
The rates of concomitant LDL-C and apo-B success and
failure according to categorizations
Table 3 shows the rates of concomitant LDL-C and apo B
success and failure according to categorizations. The highest
rates of failure in attaining both goals simultaneously were
Table 1 Clinical and lab characteristics of over 2,000 patients according to varying categorizations
Characteristics All patients [IQR] CAD alone [IQR] DM alone [IQR]
Coexistence of CAD
& DM [IQR]
P value
N 2,172 490 1,482 200
Age (year) 67 [59-75] 67 [59-75] 67 [59-75] 67 [60-76] 0.8345
Male (%) 66.85 80.00 61.74 72.50 <0.0001
Hypertension (%) 76.43 66.94 79.28 78.50 <0.0001
Diabetes (%) 77.44 0.00 100.00 100.00 <0.0001
Lipid lowering therapy (%) 66.30 100.00 50.61 100.00 <0.0001
TC (mmol/L) 3.87 [3.13-4.69] 3.32 [2.74-3.98] 4.15 [3.40-4.91] 3.40 [2.91-4.19] 0.0001
LDL-C (mmol/L) 2.25 [1.78-2.99] 1.97 [1.43-2.32] 2.50 [2.09-3.16] 2.10 [1.51-2.54] 0.0001
HDL-C (mmol/L) 1.00 [0.90-1.18] 1.00 [0.90-1.18] 1.01 [0.90-1.19] 0.96 [0.89-1.10] 0.0004
TG (mmol/L) 1.26 [0.87-1.95] 1.08 [0.80-1.62] 1.32 [0.91-2.02] 1.25 [0.82-2.11] 0.0001
Apo A1 (mmol/L) 1.22 [1.09-1.34] 1.19 [1.09-1.33] 1.23 [1.11-1.35] 1.17 [1.03-1.27] 0.0001
Apo B (mmol/L) 0.88 [0.71-1.06] 0.76 [0.62-0.93] 0.93 [0.76-1.10] 0.83 [0.68-0.98] 0.0001
Blood sugar (mmol/L) 6.50 [5.26-8.47] 5.18 [4.70-5.73] 7.23 [5.82-9.30] 6.70 [5.32-8.39] 0.0001
Lp(a) (mg/L) 93 [41-222] 98 [45-301] 91 [39-201] 108 [39-273] 0.0280
Continuous variables are expressed as median [IQR] as these variables are all not distributed normally. Categorical variables are
expressed as percentages. LDL-C, low density lipoprotein cholesterol; Apo B, apolipoprotein B; TC, total cholesterol; HDL-C, high
density lipoprotein cholesterol; TG, triglycerides; Apo A1, apolipoprotein A1; CAD, coronary artery disease; DM, type 2 diabetes
mellitus; Lp(a), lipoprotein (a); IQR, interquartile range.

4. 101Cardiovascular Diagnosis and Therapy, Vol 5, No 2 April 2015
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Table 2 LDL-C success rates versus Apo-B success rates across varying categorizations
Characteristics All patients CAD alone DM alone Coexistence of CAD & DM P value
N 2,172 490 1,482 200 –
LDL-C success (%)
Male 29.82 46.43 20.66 42.76 <0.0001
Female 18.75 35.71 14.46 32.73 <0.0001
Overall 26.15 44.29 18.29 40.00 <0.0001
Apo-B success (%)
Male 41.87 57.40 33.88 50.34 <0.0001
Female 29.58 48.98 25.57 36.36 <0.0001
Overall 37.80 55.71 30.70 46.50 <0.0001
Categorical variables are expressed as percentages. P value indicates comparisons among all categorizations. LDL-C, low density
lipoprotein cholesterol; Apo B, apolipoprotein B; CAD, coronary artery disease; DM, type 2 diabetes mellitus.
Table 3 Concomitant LDL-C and apo-B success and failure rates according to categorizations and to sexes
Characteristics All patients CAD alone DM alone Coexistence of CAD & DM P value
N 2,172 490 1,482 200
LDL-C success & Apo-B success (%)
Male 27.62 43.88 18.80 39.31 <0.0001
Female 17.36 35.71 13.76 21.82 <0.0001
Overall 24.22 42.25 16.87 34.50 <0.0001
LDL-C success & Apo-B failure (%)
Male 2.20 2.55 1.86 3.45 0.6620
Female 1.39 0.00 0.71 10.91 <0.0001
Overall 1.93 2.04 1.42 5.50 0.0001
LDL-C failure & Apo-B success (%)
Male 14.26 13.52 15.08 11.03 0.7080
Female 12.22 13.27 11.82 14.55 0.9270
Overall 13.58 13.47 13.83 12.00 0.9160
LDL-C failure & Apo-B failure (%)
Male 55.92 40.05 64.26 46.21 <0.0001
Female 69.03 51.02 73.72 52.73 <0.0001
Overall 60.27 42.25 67.88 48.00 <0.0001
Categorical variables are expressed as percentages. P value indicates comparisons among all categorizations. LDL-C, low density
lipoprotein cholesterol; Apo B, apolipoprotein B; CAD, coronary artery disease; DM, type 2 diabetes mellitus.
found in DM alone patients (P<0.0001). On the contrary,
the success rates of both goals were highest in CAD alone
patients (P<0.0001). Strikingly, 13.58%, 13.47%, 13.83% and
12.00% of patients who failed to attain LDL-C goal attained
apo B goal in CAD alone, DM alone, and coexistence of
CAD and DM, respectively. Conversely, 1.93%, 2.04%,
1.42% and 5.50% of patients who failed to attain apo B goal
attained LDL-C goal in all patients, in CAD alone, DM
alone, and coexistence of CAD and DM, respectively.
Discussion
The most important finding of the current study is
the significant differences for apo B and LDL-C goal

5. 102 He et al. Goal attainments and their discrepancies for LDL cholesterol and apo B
© Cardiovascular Diagnosis and Therapy. All rights reserved. Cardiovasc Diagn Ther 2015;5(2):98-103www.thecdt.org
attainments, with the former being higher than the latter
in Chinese patients with known CAD or DM. This finding
is particularly striking, we think, in the context that apo B
appears to be a more accurate marker of cardiovascular risk
prediction than LDL-C. Overall, the success rates for apo
B goal attainments are 10 percentage points higher than
those for LDL-C’s. This phenomenon can be found across
all categorizations. Also, the success rates for apo B goal
attainments are 10 percentage points higher for LDL-C’s
in men than in women across all categorizations. A study
from South Korea has revealed that apo B precedes LDL-C
in goal attaining after 6 weeks’ treatment of rosuvastatin
or atorvastatin in patients with metabolic syndrome and
hypercholesterolemia (8). In that study, the mean value of
apo B is 0.71 and 0.78 g/L (all <0.8 g/L) in rosuvastatin
group and in atorvastatin group, respectively, while the mean
value of LDL-C is 2.19 and 2.55 mmol/L (all >1.8 mmol/L)
in rosuvastatin group and in atorvastatin group,
respectively (8). Another study from Japan, including
39 patients with abnormal glucose tolerance and CAD,
has showed similar findings. The mean value of apo B is
0.73 g/L, which is below the cut-off of 0.8 g/L after the
combination therapy of ezetimibe and atorvastatin, while
the mean value of LDL-C is 2.14 mmol/L, which is above
the cut-off of 1.8 mmol/L after the same combination
therapy (9). On the contrary, a large sample study from
the Western world has revealed that apo B lags behind
LDL-C in goal attainments after 6 weeks’ of simvastatin/
ezetimibe or atorvastatin therapy in patients with
hypercholesterolemia and metabolic syndrome. The mean
value of LDL-C is below the cut-off of 1.8 mmol/L while
the mean value of apo B remains above the cut-off of
0.8 g/L (10). Ballantyne et al. studied the effect of ezetimibe/
simvastatin vs. atorvastatin or rosuvastatin on modifying
lipid profiles in patients with diabetes or metabolic
syndrome and found that the both mean values of LDL-C
and apo B failed to attain the goal levels of 1.8 mmol/L
and 0.8 g/L, respectively (11). A Meta-analysis, including
27 randomized clinical trials, confirmed the lower goal
attainment for apo B than for LDL-C in hyperlipideamic
patients in Western countries (12). Very few literatures
are available to report apo B and LDL-C measurements
simultaneously in East Asia and, thus, to provide the limited
information about their goal attainments. The above-
mentioned 2 studies (8,9) from East Asia are small-sampled
and underrepresented. However, the conclusion that apo B
precedes LDL-C in goal attainment in East Asian appears
to be confirmative if we take into account the current
study, which includes over 2,000 Chinese patients. The
differences for apo B and LDL-C goal attainments between
the East Asia and the Western countries perhaps implicate
the established occurrence differences for CADs and for
stroke between the East Asia and the Western countries
(13,14) given that apo B is superior over LDL-C for CAD
prediction but not for stroke (15).
Previous studies have confirmed the comparative
decrease in the cardiovascular events for women and
for men with the statin therapy (16,17).The sex-related
differences, however, were noteworthy in apo B and
LDL-C attainments and in lipid lowing therapy across all
categorizations. Male patients dominated over female ones
in incident CAD and DM. The reasonable explanation for
the sex-related differences in apo B and LDL-C attainments
seems to be the higher rates of lipid lowing therapy in men
than in women in the current study. The higher rates for
apo B and LDL-C goal attainments and for lipid lowing
therapy in men than in women indicated the presence
of care gaps reported in the literatures (18,19) and an
opportunity to improve clinical cardiovascular outcomes for
women.
In conclusions, this is the first large sample study to
compare the apo B and LDL-C goal attainments in Chinese
patients with known CAD or DM. The current study has
revealed the discrepancies of apo B and LDL-C in goal
attainments on stable statin therapy for at least 3 months.
Whether the discrepancies are associated with the
occurrence differences for CAD and for stroke between the
East Asia and the Western countries warrants further study.
Acknowledgements
Disclosure: The authors declare no conflict of interest.
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